Optical coherence tomography in children with coeliac disease

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Coeliac disease (CD) is a gluten-sensitive enteropathy occurringingeneticallypredisposedindividualsandcharacterisedbychronicinflammationofthesmallintestinalmucosathatgraduallyleadstovillous atrophy. It typically results in malabsorption of most nutri-ents, but its clinical expression is highly variable [1].The gold standard for the diagnosis of CD is the histologicaldemonstration of characteristic pathological changes that are cat-egorised according to the Marsh classification and modificationsthereof [2]. As the small bowel mucosal damage in CD can be dis-tributed in a patchy fashion, with parts of the mucosa apparentlynormalintermingledwithothersseverelydiseased(‘patchyvillousatrophy’),itisimportantthatfourtosixbiopsies,includingaduode-nal bulb biopsy, are taken from the proximal small intestine duringupper endoscopy [3].The diagnosis of CD may, therefore, also depend on the endo-scopic appearance of the duodenal mucosa. Several endoscopicmarkers related to CD have been identified and include featuressuch as a nodular and/or a mosaic pattern of bulb and duodenalmucosa, reduction or loss of duodenal folds, scalloping of valvu-laeconniventes,visibilityofsubmucosalvessels[4].Thesemarkersare often used both to determine whether duodenal biopsies areindicated and to target the sites of the biopsy. Among several stud-ies, the overall sensitivity and specificity of endoscopic markersof CD vary from 6% to 94% and from 83% to 100%, respectively[4]. In clinical practice, recognising any suspicious mucosal fea-tures for CD should alert the endoscopist to the need to biopsy themucosa. However, the rather low sensitivity of these features sug-gests that their absence does not exclude an underlying CD andbiopsies should always be obtained when CD is suspected, eitherclinically or by serological assays. In individuals undergoing upperendoscopyforsymptomsotherthanmalabsorption(e.g.functionaldyspepsia, acid-related disease) duodenal biopsies might not betaken and diagnosis of CD missed. On the other hand searching forCDinsuchpatientsisnotrealistic,consideringthesignificantcostsof pathological processing.